The Risk Of Perpetuating Health Disparities Through Cost-Effectiveness Analyses

Cost-effectiveness analyses are commonly used to inform health care and public health policy decisions. However, standard approaches may systematically disadvantage marginalized groups by incorporating assumptions of persisting health inequities. We examined how competing risks, baseline health care costs, and indirect costs can differentially affect cost-effectiveness analyses for racial and ethnic minority populations. We illustrate that these structural factors can reduce estimated quality-adjusted life-years and cost savings for disadvantaged groups, making interventions focused on disadvantaged populations appear less cost-effective. For example, analyses of a sugar-sweetened beverage tax may estimate higher costs per quality-adjusted life-year gained for Black versus White populations because of differences in competing risks and insurance status that manifest in higher health care cost savings from averted disease among White people. To ensure that cost-effectiveness assessments do not perpetuate inequities, alternative approaches are needed that account for the impact of structural factors on different groups and that consider scenarios in which health inequities are reduced. Sensitivity analyses focusing on health equity could help advance interventions that disproportionately benefit disadvantaged communities.